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It surprised me. Looking at the title of the piece, I thought it might be about the emotional toll of practicing medicine, which may contribute to rates of drug abuse, divorce, and suicide among physicians that are higher than in the general population. Or, I thought it might be about the level of debt medical graduates carry (average $170,000 for 2012 graduates), or about low rates of job satisfaction among American physicians, especially among ever busier primary care doctors. But Dr. Avorn's editorial is about none of these. It's about the overwhelming flood of information which doctors must absorb to stay current. What used to be a tall but manageable stack of journals in one's own specialty has now become a daily deluge of Internet updates, most of which patients, too, are seeing and asking about. He points to the perils of trying to distill medical information into practice "guidelines" which, in some cases, have nudged doctors towards prescribing expensive drugs or tests. Dr. Avorn makes some interesting suggestions about how to avoid this pitfall, including a system adopted by Australia and also by Kaiser Permanente in which an impartial guide, without financial ties to pharmaceutical companies or other commercial enterprises, "curates" data to help physicians navigate the sea of information. I like the idea of a curator, but I must say, my own main source of stress as a primary care doctor has less to do with my inability to keep up with the daily flood of information than the pressure I feel to see patients more and more quickly. (I wrote a column about this in the Globe last year). For me, some of the most satisfying moments I experience in medicine come when I have time to really think through a problem and then use the minimal amount of technology to diagnose and treat it. For example, I just recently I saw an elderly man with blood in his urine. This is a frightening symptom with many possible causes: urinary and prostate infections, trauma, kidney stones, tumors of the bladder and kidney, bleeding disorders. My goal was not only to diagnose the man's bleeding, but to do it as quickly and painlessly as possible. Most helpful to me in doing this was--counterintuitively, perhaps--slowing down . A detailed history (the fact that there was no pain with the bleeding was important) and physical exam (there were no signs of trauma, he had none of the flank tenderness usually seen with stones, and the prostate gland wasn't tender) gave me most of the information I needed. After that, I felt confident that a single test would reveal the diagnosis and it did: a CAT scan showed a bladder tumor. Within hours, the man was seeing a urologist. I wasn't happy that the man had a tumor, but I did feel good about getting him on the road to treatment so soon. There's one source of information that, somehow, never feels overwhelming: the patient. |
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